1
2018 Nicolas E. Davies Enterprise Award of Excellence
Case Study: Census Reporting And
Clinical Pathway Management To Improve Capacity And Optimize
Patient Care
Dawn Williams
Manager, Patient Access Services
Kelli Nelson
Director, Clinical Applications
2
Part I: Census Reporting
Dawn Williams
Manager, Patient Access Services
3
Census Reporting Problem Background
PAS tasked with bed management for more than 18,500 orthopedic
inpatient surgeries annually
Requires close monitoring of bed utilization to accommodate patient
volume
Hospital bed census communicated to HSS leadership and
operational owners four times per day
Manual data collection process presented significant operational
challenges
Multiple telephone touchpoints with nursing units throughout the day
Data often based on subjective estimates
Minimal ability to cross-train due to process complexity, resulting in staffing
challenges
After the implementation of our EHR, operational & IT leadership
looked for a way to leverage new technology to transform the bed
planning process
4
Inadequate reporting tools
No real time monitoring
No ability to reliably track patient throughput
Critical billing related notes lost after discharge
Limited visibility of patient’s admission details
Existing platform wasn’t user friendly, requiring a lot of manual
clicks
Inability to use indicators or communicate updates to other users
Resulted in repeated calls/email among staff members
Often resulted in duplicate work
Challenges With The Prior Census
Report Process
A more accurate and timely census report would support daily capacity
planning and execution
5
Census Notification Process
6
Deliver an ‘At a Glance’ view of the entire house
Implement tools to reduce PACU overnight volume
Proactively anticipate capacity volume
Develop solutions to accommodate future admissions
Implement tools to reduce PACU bed turnaround
Bed assignment & availability
Automate daily projected census reporting
Develop a solution better suited to scale and train across skill sets
Goals & Objectives For Improvement
7
Operational
owners, vendor,
and IT met to
discuss current
state workflow
and data
collection
Pulled in front-end users
Talked with end-users about data they provided
and how determined
Scrutinized each data point to understand which
we could automate
Vendor proposed
solutions and
guided IT in
initial build
Proposed solutions were reviewed
Completed build for initial dashboard
Circulated initial
build with
stakeholders for
buy-in
Stakeholder review draft
dashboard
Visited each stakeholder
individually to understand unique
concerns
Revised build based on
stakeholder feedback
Monitored data
via parallel
process
Refined build
and ceased
parallel process
monitoring
Design Methodology
Plan
Do
Check
Act
PDCA
Allowed dashboard to calculate
data
Compared to results of prior
process
Shared variance data with
stakeholders
Refined build based upon
feedback
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Validation Method
Parallel process review
Daily review of variance
Investigate with various stakeholders
Modify variables and monitor outcomes
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Technology Leveraged: HSS Capacity
Management Dashboard
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Data Collection
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Implementation: Staff Training
Staff Instructions
Enter data from the ADT Capacity
Management Dashboard into the orange
portions of the excel template above
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People Trained 5 19
Work Effort/Census
Notification
45 min - 1 hr 4-5 min
Value Derived
2016 2018
96% Reduction in OR cases put on hold due to PACU bed
shortages (2015 vs 2018)
o Decreased overtime hours associated with OR holds
o Increased OR utilization
Improvements resulted in increased flexibility of PAS staff
Increased capacity allowed PAS leadership to establish a
3
rd
shift without adding FTEs
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Bed Assignment & PACU Turnover
(Calculated in Minutes)
Outcomes
60
42
49
20
23
23
22
17
71
78
82
108
0
20
40
60
80
100
120
140
160
2017 Q1 2017 Q2 2017 Q3 2017 Q4
Avg RTP to Assigned Avg Assigned to Bed Ready Avg Bed Ready to Occupied
Transfer out of the PACU depends on inpatient capacity
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Part II: Clinical Pathway
Management
Kelli Nelson
Director, Clinical Applications
15
At HSS, Clinical Pathways Are
Procedure Specific Post Op Order Sets
That Coordinate And Standardize Care
Pathways Overview
Time based goals/milestones for
interdisciplinary care of a defined
patient group
Procedures: Primary Hip, Primary Knee, etc.
Disease states: Diabetes, Kidney, CVD, etc.
Created to reduce variation in care and
increase value for similar patient groups
Pathways at HSS
EMR order-sets: post-op through discharge
Documented by clinical teams and reviewed in
rounds
Inpatient pathways cover more than 80% of
HSS inpatients
Several ambulatory pathways recently
developed
Pathway performance is measured as “Pathway LOS Adherence”
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Pathway LOS Adherence Is When A
Patient Discharges By Their Pathway
Length Of Stay Goal
Adhered Did Not Adhere
Pathway
LOS Goal
Surgery
Discharge
Discharge
Surgery
At HSS, there is no margin of error in LOS Adherence
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In 2016, Overall Pathway LOS
Adherence Stabilized At ~40%
For every 10 patients, 4 adhered to their pathway
Pathway LOS Adherence By Month, 2016
Average = 40%
Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16
60%
50%
40%
30%
20%
10%
0%
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If All HSS Patients Adhered To
Pathways, HSS Would Gain More Than
300K Bed Hours Per Year
Addressing root causes of “off pathway” pts. will improve resource use
Off Pathway On Pathway
Pts Per
Year
X hours
~307.5K Bed
Hrs/Year
(~35 beds)
Inpatient Average
Length Of Stay
Off Pathway
Patient Count
Total Bed
Hours (Capacity)
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To Improve Pathway Adherence, An
Interdisciplinary Project Team Was
Chartered
Problem
Statement
HSS
patients are not always discharged within expected length of stay as determined by clinical pathways
Scope/Activities
& Deliverables
Develop/refine reporting and measurement
Determine top 5 contributors to adherence and isolate clinical vs. non clinical (operational) causes
Recommend new pathways for development and pathways changes to achieve better adherence (e.g.,
LOS Targets)
Establish action plans and implement operational changes (e.g., “Pathway Clock” workflow design)
Metrics
# Description Baseline Target Standard
1
ALOS
2
Pathway Adherence
40%
3
Pathways Discharge Delay (
Avg)
4
ID Top 5 Causes Of
Noncompliance
Benefits
1.
Proactive management of patient care
2.
Clinically appropriate length of stay
3.
Decreased costs for HSS and patient-family
3.
Staff satisfaction with plan of care
documentation
4.
Patient satisfaction and quality of care
Team
Members
Leadership Team Ad Hoc
Sponsor(s)
Ops. Owner(s)
Op. Ex.
Case Management
Nursing
Nutrition
Physician Assistant
Physician
Pharmacy
Physical Therapy
Information Technology
Value Management
Informatics
Patient Care
Directors
Physicians
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The Project Team Followed A Design
Thinking Approach
Discovery
“What Are We
Solving?”
Ideate
“How Could We
Do That?”
Prototype
“What Does It
Look Like?”
Test
“Does it ‘Mostly’
Work?”
T - 8 Weeks
Identify hypotheses
Gather data
Observe
Validate data
Analyze data
Review preliminary
findings with
stakeholders
Revise analysis
Make opportunity
recommendations
Brainstorm “how” to
move from concept to
design
Propose and discuss
ideas
Identify and sort by
selection criteria
Agree to full solution
set (i.e., impact
multiple
roles/processes and
environments)
Quickly build
solutions (e.g., a
storyboard, or a new
process flow)
Trial solutions (e.g.,
role-play)
Ask “why”
Deliberately plan
your test (scenarios &
experience questions)
Ask users to try
Solicit feedback (Ask
“why”)
Build feedback into
design and revise the
prototype (PDCA)
Plan for launch
Performance gap is
measured
Opportunity
(“Challenge”) is clear
Common underlying
issues are agreed
Multiple ideas
considered
Best solutions
identified
Ideas checked for
flaws
Communication
started
Soft failures / Redo
Prototype refined
User approval
User buy-in
Idea is ready for
implementation
Plan to implement
Activities
Outcomes
In this approach, the discovery phase starts with data analysis
Kickoff
T + 2 Weeks
T + 4-8 Weeks
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The Team’s Review Of Data Identified
Distinct Groups Of Patients That Do Not
Adhere To Pathways
The hour of surgery and complexity are primary drivers of adherence
Group A:
Patients Exit OR
Earlier Than On
Path Patients
Group B:
Patients Are
Moderately
Complex
Group C:
Patients Are
Significantly
More Complex
Same pattern
exists across all
pathways
Among Patients Who Go Off Path, ~72% Are Off By ≤30 Hours
3 Distinct Groups: (A) 0-12 Hrs Off Path, (B) 18-30 Hrs Off Path, (C) All Others
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
100
200
300
400
500
600
1
7
13
19
25
31
37
43
49
55
61
67
73
79
85
91
97
103
109
115
121
127
133
139
145
151
157
163
169
175
181
187
193
199
Volume
Hours
Group A Contains ~40%
Of Off Path Patients
Group B Contains ~32%
Of Off Path Patients
Moving All Group A
Patients On Path Would
Result In ~66%
Adherence Overall
Moving Group B On Path
Would Result In ~62%
Adherence (Exclusive Of
Group A)
Moving Both A And B
Together On Path Would
Result In 85% Adherence
Rate Overall
Distributions Are Similar
For Each Pathway And
For Each Specialty
Key Insights
Group A
Group Avg. Hrs
Off Path
% of
Pts
A 3.1 40%
B 23.8 32%
C 55.5 28%
Group C
Group B
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Despite Patient Types, One Procedure
Specific Pathway Was Available For
Patients, Leading To Bottlenecks At
Discharge
Pathways were not built for patient differences and were unreliable
frameworks for planning/execution
Surgeon Performs
Surgery
First Assist
Places The
Pathway Order
Surgery Recovery
Interdisciplinary
Rounds (2x/Day)
Team States DC
Date And What Else
Patient Needs To DC
Discharge
Discharge Time
Determined On
DC Date
Key Problems Significance
Pathways “one
size fits all”
Few patients discharge on pathway - progress appeared random
Priority patients could not be easily identified in work queues (e.g.,
by medical complexity, discharge targets)
DC Date/time
targets
unspecified
Discharge times determined on day of discharge
Tasks to prepare for discharge could not be prioritized/coordinated
Discharge bottlenecks and patient, family, and staff complaints
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Today, Pathways Have Multiple Levels
And Discharges Are Scheduled,
Allowing Teams To Prioritize And
Cascade Work
A shared, realistic LOS target provides the foundation for coordination &
more effective care delivery
8/10/15; 1012
8/12/15; 0806
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
8/10/15; 1012
1 Short LOS
2 Standard
3 Long LOS
X Hours
Y Hours
Z Hours
Perioperative
Team Identifies
Complexity
First Assist Places
Specific Pathway
Order: Level 1-3
Key
Insights
Expected DC time driven by pathway order (placed by first assist)
Pathway LOS is “individualizedfor patient needs (low to high complexity)
Teams queue & organize workflows by the exp. Discharge time
Patients/families prepared for discharge, allowing them to meet/beat goal
Surgery Recovery
Interdisciplinary
Rounds (2x/Day)
Case Mgr. Provides DC
Target, Team Aligns Care Plan
& Prioritizes Work
Discharge
Discharge By The
Hour Targeted
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Several EMR Changes Were Required
To Operationalize The New Process,
Starting With The Pre-Op Clearance
Note
Key
Insights
1. Pre-op the internist documents a pathway level suggestion
2. Post op, the first assist places a final pathway order
3. Once inpatient, the case manager reviews and documents an
expected discharge date/time
1
2
3
Pre Op Clearance Note
Expected Discharge Date/Time
Pathway Order Selection
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Additional Changes Included
Visualizing The Discharge Goal To Align
Interdisciplinary Work And Patient
Expectations
Key
Insights
1. Patient lists with date/time of discharge for staff and patients
2. IPOC panel with expected discharge and pathway details support
interdisciplinary rounds
3. In-room TV display of scheduled discharges
1
2
3
TV Display
Electronic White Board
IPOC Panel
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In Addition, An Interdisciplinary
Rounds Standard Was Created To Help
Coordinate Care Along Pathways
Question
Responsible
Words That Work
I
dentify
Who is the patient?
Why are they here?
RN
“10
-01, Mrs. Jones, patient of Dr. Haas, left knee. Post-
op day 1 and wants to leave tomorrow.
Disposition
What is the disposition and
expected DC date/time?
Case Mgr.
The preop note says she is going home. Currently
expected to go home with services on Friday at 10 am.
O
bstacles
Are they progressing
toward their disposition?
What are the remaining
barriers?
RN
PT
PT
RD
Pharm.D.
Case Mgr.
RN:
No issues overnight.
PA
: “She had drainage but now wound is healing nicely.
PT
: “She’s progressing well, ambulated 50x2 and is
listed for PT today at 11 am and 2 pm.
RD:
“Her diet can be advanced to Regular.
Case
Mgr: Home care is arranged.
C
hange
Is it possible to discharge
the patient earlier/later?
Should the disposition be
changed?
PCD
“She’s doing well. Is there an opportunity to move her
to an earlier discharge? What’s the best disposition we
could achieve?”
IF BARRIERS
: What can we
do to remove the issue or
improve the disposition?
Who is gong to take action?
PCD
“What needs to be done to get the patient back on
pathway? Do you need help?”
OR
“[PT],
will you assign them a morning mobility session?”
S
hare
IF
DC Plan or Disposition
Changes
: Who will tell the
patient?
PCD
“Since this is a big change to their plan and they are
medically ready, can [PA/MD/RN] please make sure that
Mrs. Jones’ & her family are aware?”
HSS Rounding Standard
All rounds include a
specific focus on
patient’s discharge goal
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Phlebotomy Workflows Were Also
Aligned To Pathways Through An
Updated Worklist
Workflow Changes
Phlebotomists draw labs in order of
the expected discharge
Work queues now display patients
in order of expected discharge
Display shows patients with
expected discharge within next 6
hours
Impact
Small batches improve lab
turnaround times
Ensures test results are available
by start of rounds
Improves decision making and
likelihood of meeting discharge
time
Updated WorklistPrevious Worklist
Patients
expected to
discharge
within 6 hours
All patients on
phlebotomist
worklist
28
A Performance Dashboard Now
Provides Daily Feedback To Each
Interdisciplinary Team
Data removed
29
Results
30
Since Go-Live, Pathway ALOS Has
Declined By ~6.5 Hours And Is Now
Nearly Equal To The Expected LOS
Delivering the expected ALOS allows for better planning
Pathway ALOS
Expected Pathway ALOS
ALOS (Hours)
60.4
Pathway ALOS By Month, 2016 2018 YTD
1, 2, 3
Avg = 68
Pathway Levels
Go-Live
Avg = 71
-6.5 Hrs
Avg = 61.5
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The ALOS For Complex Pathway
Patients Decreased ~9 Hours
ALOS (Hours)
Avg = 93
Pathway Levels
Go-Live
Gaps in care are closing and coordination of care is better, even for most
complex of patients
Complex Patient ALOS By Month, 2016 2018 YTD
1, 2
Avg = 84
-9 Hrs
32
Most Of The ALOS Change Occurred
Within The IP to Clear Rehab Phase
LOS (Hours)
ALOS By Phase of Encounter Before & After Pathway LOS Adherence Project
All Pathways
Primary Hip and Knee Pathways
PACU
IP to Clear
Clear to DC Order
Discharge
Hip
Knee
51
47
56
52
35
41
Before After
After
After
Before
Before
LOS (Hours)
33
Aligning Phlebotomy To The Expected
Discharge Date/Time Increased The
Rate Of Labs Resulted By Rounds
Timely labs allow clinical teams to make decisions regarding discharge
and keep patients on pathway
Percent of Labs Resulted By Start Of Morning Rounds
Hematology
Chemistry
Worklist
Change
Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
+20%
+19%
34
Overall Pathway LOS Adherence
Increased By 13%
Pathway LOS Adherence By Month, 2016 - 2017
LOS
Adherence
(%)
53%
+13%
Aug Dec 2017 saw 5 consecutive months of record LOS adherence
Main
Project
Go-Live
Baseline Avg = 40%
Avg = 45%
35
Greater Pathway Adherence Has
Created Capacity For Additional
Surgical Cases
Greater Adherence
Inpatient Capacity
Created
+13% Adherence
Bed Capacity
600 1200
Surgical Cases
Potential For
Surgical Volume
36
HSS developed and hardwired a
system to manage each patient by
their pathway
Pathway segmentation
Discharge scheduling with LOS goals
Supporting department work queues
Overall Results:
+13% net pathway LOS adherence
Represents a 33% improvement
5 consecutive months of record rates
10% ALOS decrease
6.5 hour pathway LOS decrease
Additional capacity for 600 - 1200
surgical cases
Recap: HSS Has Created A Pathway
Management System
Despite improvements, large opportunities exist for 2018 and beyond
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Next Steps
38
Building On Past Work, HSS Pathways
Will Become More Personalized
Past Present Future
One pathway per
procedure
Multiple pathways per
Procedure
Personalized
pathways per Patient
12
Pathways
35
Pathways
Unlimited
Pathways
Pathway Count
Personalized pathways will require more clinical coordination, flexible
operations, and rapid development cycles
Level 1
Level 2
Level 3
39
Soon, Pathway Development Will Be
Driven By A Steering Committee
On-Going Support
Review data
Review high risk
patient cases
Project
management
Prioritization
Identify highest
priority updates
Ensure alignment
to org. Priorities
Production Sched.
Development
Dev. cycles
Build new
pathways
Adjust existing
pathways
Educate staff
Pathways
Steering
ProcessStructure
Spine
Team
Knee
Team
Hip
Team
Shoulder
Team
Foot
Team
Peds
Team
Other
Team
Trauma
Team
Output
Impact
Clinical
Effectiveness
Distinct
Continuous
Improvement
Strategic
Alignment
Consistent
Communication
Team Based
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Gather prevailing hypotheses and use data to A) separate myth from fact and
B) identify focus for change
Use design thinking with a trusted interdisciplinary team to create
engagement and find ideal solutions
Rank your solutions against the original problem (data)
Be creative with your EMR: The perfect solution may not be feasible but a
“better” state is always possible
Communication never ends: Ensure all stakeholders have the opportunity to
evaluate the team’s solutions before moving forward
Consider what might happen if you are too successful (e.g., budget impact)
Systemic alignment occurs when you establish shared goals that can be
operationalized within workflows
Lessons Learned
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Appendix 1: Inpatient Pathway
Adherence 2016 - 2018
Pathway LOS Adherence By Month, 2016 - 2018
LOS
Adherence
(%)